Provider First Line Business Practice Location Address: 
1055 CLERMONT ST, 111C 6C-120
    Provider Second Line Business Practice Location Address: 
VA MEDICAL CENTER
    Provider Business Practice Location Address City Name: 
DENVER
    Provider Business Practice Location Address State Name: 
CO
    Provider Business Practice Location Address Postal Code: 
80220
    Provider Business Practice Location Address Country Code: 
US
    Provider Business Practice Location Address Telephone Number: 
303-399-8020
    Provider Business Practice Location Address Fax Number: 
    Provider Enumeration Date: 
09/15/2006